The risks associated with multiple pregnancies are generally accepted to be greater than those of singletons. Stillbirth risk for twins is more than twice that of a singleton, and greater still for triplets (TAMBA, 2007). Neonatal morbidity and mortality is also higher. However, as obstetric litigation increases, obstetricians can place disproportionate emphasis on these risks when counselling women. Consequently, most women choose consultant-led units for delivery (Kalish & Skupski, 2002). For some though the idea of a hospital birth and the interventions likely to accompany, it contradicts the ethos of ‘normal birth’, and they choose homebirth. Women considering this option may benefit from the care of an independent midwife, who may have more experience in caring for women with multiple births at home.

Many women carrying twins can enjoy safe vaginal births (El Halta (1996) cited by Evans (2000)). However, a lack of research into higher-order births results in practice varying worldwide. In the UK, where obstetricians are the lead caregiver, 59% of all twins and almost all triplets and higher-order births deliver by elective CS (Kalish & Skupski, 2002). This begs the question: ‘Are women offered true choice or are their decisions swayed by obstetricians who lean towards a more medical view of birth?‘

A woman’s choice regarding twin birth is usually influenced by the presentation of the babies. Most commonly, they present vertex/vertex (~40%), followed by vertex/nonvertex (~30%), non-vertex/vertex (~20%) and non-vertex/non-vertex (~10%) (Blickstein, 2005). Historically, obstetricians have recommended CS for any woman whose leading twin is non-vertex. However, evidence suggests that other factors are of greater or equal importance in determining a safe vaginal delivery, such as predicted birth weights (Blickstein, 2005).

In the UK, almost all triplets and quadruplets are delivered operatively (Kalish & Skupski, 2002). It is unclear whether this is due to lack of an evidence base or because of rising litigation. Interestingly, evidence from studies in other countries, including USA, concludes outcomes for mothers and babies are improved by vaginal delivery, providing it is in a hospital and attended by appropriately skilled clinicians (Grobman et al., 1998). This is mainly due to a reduction in post-operative complications for mothers and a lower incidence of respiratory distress syndrome in babies. Sheppard et al. (1999) support this, highlighting the fact that mothers recover more quickly following vaginal birth, and are therefore better placed to begin caring for their babies. It seems UK women may be currently disadvantaged as obstetricians continue to routinely advocate elective CS for triplets and higher-order births.

Care in labour

Midwives’ knowledge and understanding of normal birth is invaluable when caring for a mother of twins in labour. This is sometimes a difficult role, as the midwife must act as an advocate for the mother whilst working alongside obstetric colleagues. The key is to remember that women’s choice is the priority and that those who feel empowered to make informed decisions are more likely to feel at ease and have a positive outcome.

If the birth is in hospital, women may wish to look around the unit at some stage during their pregnancy. A tour of NICU/SCBU may be appreciated as around 50% of twins and almost all triplets will require admission (TAMBA, 2006b). This is mainly due to low birth weight resulting from prematurity. Prematurity is one of the most significant risks associated with multiple pregnancies, and midwives must be aware of the implications when caring for women in labour (see Chapter 12).

In hospital, when the woman is in labour the midwife should inform the relevant professionals. The birthing room should be prepared adequately with equipment checked and accessible. Instrumental delivery or theatre preparation equipment should be nearby but not visible as this may disturb the birthing environment and concern the woman unnecessarily. Likewise, in the absence of complications, there is little need for anyone other than the attending midwife to be in the room, usually joined by a second midwife during the second stage.

Care during the first stage of labour should be similar to that offered to any woman. A calm, kind midwife who offers appropriate explanations and plenty of praise and reassurance will help ensure the woman feels safe and confident. There are some special considerations for twin mothers:

• Positioning. The woman should be comfortable and able to mobilise freely, maintaining an upright position to aid labour progress. The increased uterine size in a multiple pregnancy can cause considerable discomfort, and frequent changes of position may be needed.
  
• Intravenous (IV) cannulation. In many hospitals it is routine practice to site an IV cannula to administer emergency drugs if complications arise. However, this is ultimately the woman’s choice and should be based on her potential risk or the condition of her veins, rather than being a blanket policy.
  
• Fasting. Some obstetricians advocate fasting or fluids only to prevent gastric aspiration if a general anaesthetic is required. Johnson et al. (2000) contest this, as gastric aspiration is associated with poor anaesthetic technique and happens even when women have fasted. Limiting a woman’s intake during labour can inhibit progress and lead to a cascade of intervention so midwives should avoid this practice. However, offering a hydrogen ion inhibitor (e.g. ranitidine, cimetidine) to encourage rapid emptying of stomach contents may confer benefits, should an emergency CS be required (Johnson et al., 2000).
  
• Epidural Analgesia. Women may feel pressured into having an epidural in case of the need for emergency procedures, e.g. cephalic version or CS. However, epidurals slow labour by reducing oxytocin levels and restricting mobility. This leads to interventions, e.g. IV oxytocin and instrumental delivery (Dickersin, 2000). The midwife should ensure that the woman is appropriately informed and support her decisions. This includes discussion regarding other suitable forms of analgesia.

Monitoring the fetal heart rates

There is much debate as to whether continuous or intermittent auscultation is the best option during a twin labour. NICE guidelines advocate continuous electronic fetal monitoring (National Institute for Health and Clinical Excellence (NICE), 2007), although the evidence underpinning this is debatable (Beech Lawrence, 2001). It is often restrictive and uncomfortable for women and is associated with increased intervention (Grant, 2000; NICE, 2007). Intermittent auscultation may be preferable although the difficulties in locating two or more heartbeats can make it impractical. In practice, midwives are usually under pressure to perform continuous cardiotocograph (CTG) although this is not always practicable either. Ultimately, women have the right to choose and may decline electronic monitoring or prefer to have only periodic CTG traces. The following points offer some guidance for both methods:

• Intermittent auscultation